Utility of a quick diagnostic unit during the SARS-CoV-2 pandemic for the diagnosis of cancer.

OBJECTIVES: To analyse changes in health care activity, time of referral and diagnosis intervals and the incidence of cancer during the first two years of the SARS-CoV-2 pandemic in a quick diagnosis unit. MATERIALS AND METHODS: A retrospective observational study was carried out during the prepandemic year (March 1, 2019, to February 29, 2020) and the first two years of the pandemic (March 1, 2020, to February 28, 2022). Demographic and clinical variables, the first visit interval, the diagnosis interval and the first visit-diagnosis interval were evaluated and compared. RESULTS: During the first pandemic wave, there was a reduction in referrals (-32.6%), which then increased 8.1% and 17.7% from the second wave until the end of the first pandemic year and the second pandemic year, respectively. An increase in referrals to primary care and a decrease in emergencies were identified. The increase in cancer diagnoses of 2.7% and 15.7% in the two years of the pandemic was proportional to the increase in referrals. No changes were observed in benign processes or in cancer locations and stages. The first visit interval was higher for benign diseases (p<0.0001). A prolongation of the diagnosis interval was observed in cancer patients, although during the three years of the study the median was <15 days. CONCLUSIONS: The impact of the pandemic affected the length of intervals and the origins of referrals. The quick diagnosis units constitutes and urgent complementary cancer diagnostic route with a high diagnosis yield.

Predictors for individual patient antibiotic treatment effect in hospitalized community-acquired pneumonia patients.

OBJECTIVE: Our objective was to identify clinical predictors of antibiotic treatment effects in hospitalized patients with community-acquired pneumonia (CAP) who were not in the intensive care unit (ICU). METHODS: Post-hoc analysis of three prospective cohorts (from the Netherlands and Spain) of adult patients with CAP admitted to a non-ICU ward having received either ß-lactam monotherapy, ß-lactam + macrolide, or a fluoroquinolone-based therapy as empirical antibiotic treatment. We evaluated candidate clinical predictors of treatment effects in multiple mixed-effects models by including interactions of the predictors with empirical antibiotic choice and using 30-day mortality, ICU admission and length of hospital stay as outcomes. RESULTS: Among 8562 patients, empirical treatment was ß-lactam in 4399 (51.4%), fluoroquinolone in 3373 (39.4%), and ß-lactam + macrolide in 790 (9.2%). Older age (interaction OR 1.67, 95% CI 1.23-2.29, p 0.034) and current smoking (interaction OR 2.36, 95% CI 1.34-4.17, p 0.046) were associated with lower effectiveness of fluoroquinolone on 30-day mortality. Older age was also associated with lower effectiveness of ß-lactam + macrolide on length of hospital stay (interaction effect ratio 1.14, 95% CI 1.06-1.22, p 0.008). CONCLUSIONS: Older age and smoking could influence the response to specific antibiotic regimens. The effect modification of age and smoking should be considered hypothesis generating to be evaluated in future trials.

Levofloxacin versus azithromycin for treating legionella pneumonia: a propensity score analysis.

OBJECTIVES: Concerns have arisen regarding the equivalence of levofloxacin and some macrolides for treating community-acquired legionella pneumonia (LP). We aimed to compare the outcomes of current patients with LP treated with levofloxacin, azithromycin and clarithromycin. METHODS: Observational retrospective multicentre study of consecutive patients with LP requiring hospitalization (2000-2014) conducted in two hospitals. The primary outcome assessed was 30-day mortality. To control for confounding, therapy was assessed by multivariate analysis. RESULTS: We documented 446 patients with LP, of which 175 were treated with levofloxacin, 177 with azithromycin and 58 with clarithromycin. No significant differences in time to defervescence (2 (interquartile range (IQR) 1-4) versus 2 (IQR 1-3) days; p 0.453), time to achieve clinical stability (3 (2-5) versus 3 (2-5) days; p 0.486), length of intravenous therapy (3 (2-5.25) versus 4 (3-6) days; p 0.058) and length of hospital stay (7 (5-10) versus 6 (5-9) days; p 0.088) were found between patients treated with levofloxacin and those treated with azithromycin. Patients treated with clarithromycin had longer intravenous antibiotic treatment (3 (2-5.25) versus 5 (3-6.25) days; p 0.002) and longer hospital stay (7 (5-10) versus 9 (7-14) days; p 0.043) compared with those treated with levofloxacin. The overall mortality was 4.3% (19 patients). Neither univariate nor multivariate analysis showed a significant association of levofloxacin versus azithromycin on mortality (4 (2.3%) versus 9 (5.1%) deaths; p 0.164). The results did not change after incorporation of the propensity score into the models. CONCLUSIONS: In our study, no significant differences in most outcomes were found between patients treated with levofloxacin and those treated with azithromycin. Due to the small number of deaths, results regarding mortality should be interpreted with caution.

Declining mortality among hospitalized patients with community-acquired pneumonia.

Little information is available on the changes over time in community-acquired pneumonia (CAP) management and their impact on 30-day mortality in hospitalized patients. We performed a prospective, observational study of non-severely immunosuppressed hospitalized adults with CAP from 1995 to 2014. A total of 4558 patients were included. Thirty-day mortality decreased from 9.6% in the first study period (1995-99) to 4.1% in the last period (2010-14); with a progressive downward trend (-0.2% death/year; p for trend = 0.003). Over time, patients were older (p 0.02), had more co-morbidities (p 0.037), more frequently presented severe illness according to the Pneumonia Severity Index (p <0.001) and septic shock (p <0.001), and more often required intensive care unit admission (p <0.001). Combination antibiotic therapy (p <0.001) and fluoroquinolone use (p <0.001) increased. Factors independently associated with 30-day mortality were increasing age (OR 1.04; 95% CI 1.03-1.05), co-morbidities (OR 1.48; 95% CI 1.04-2.11), shock at admission (OR 4.95; 95% CI 3.49-7.00), respiratory failure (OR 1.89; 95% CI 1.42-2.52), bacteraemia (OR 2.16; 95% CI 1.58-2.96), Gram-negative bacilli aetiology (OR 4.79; 95% CI 2.52-9.10) and fluoroquinolone use (OR 0.45; 95% CI 0.29-0.71). When we adjusted for a propensity score to receive fluoroquinolones, the protective effect of fluoroquinolone use was not confirmed. In conclusion, 30-day mortality decreased significantly over time in hospitalized patients with CAP in spite of an upward trend in patient age and other factors associated with poor outcomes. Several changes in the management of CAP and a general improvement in global care over time may have caused the observed outcomes.

Impact of pre-hospital antibiotic use on community-acquired pneumonia.

Information on the influence of pre-hospital antibiotic treatment on the causative organisms, clinical features and outcomes of patients with community-acquired pneumonia (CAP) remains scarce. We performed an observational study of a prospective cohort of non-immunosuppressed adults hospitalized with CAP between 2003 and 2012. Patients were divided into two groups: those who had received pre-hospital antibiotic treatment for the same episode of CAP and those who had not. A propensity score was used to match patients. Of 2179 consecutive episodes of CAP, 376 (17.3%) occurred in patients who had received pre-hospital antibiotic treatment. After propensity score matching, Legionella pneumophila was more frequently identified in patients with pre-hospital antibiotic treatment, while Streptococcus pneumoniae was less common (p <0.001 and p <0.001, respectively). Bacteraemia was less frequent in pre-treated patients (p 0.01). The frequency of positive sputum culture and the sensitivity and specificity of the pneumococcal urinary antigen test for diagnosing pneumococcal pneumonia were similar in the two groups. Patients with pre-hospital antibiotic treatment were less likely to present fever (p 0.02) or leucocytosis (p 0.001). Conversely, chest X-ray cavitation was more frequent in these patients (p 0.04). No significant differences were found in the frequency of patients classified into high-risk Pneumonia Severity Index classes, in intensive care unit admission, or in 30-day mortality between the groups. In conclusion, L. pneumophila occurrence was nearly three times higher in patients who received pre-hospital antibiotics. After a propensity-adjusted analysis, no significant differences were found in prognosis between study groups. Pre-hospital antibiotic use should be considered when choosing aetiological diagnostic tests and empirical antibiotic therapy in patients with CAP.